NCLEX-PN
NCLEX Trainer Test 8 Questions
Extract:
Question 1 of 5
The nurse is caring for a client with a long leg cast on his right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to complain of pain even though an analgesic was administered 45 minutes ago. What is the FIRST action the nurse should take?
Correct Answer: D
Rationale: Pale, cool skin and persistent pain suggest compartment syndrome, requiring immediate physician notification. Options A, B, and C are unsafe.
Extract:
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Question 2 of 5
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
Extract:
Question 3 of 5
An insulin-dependent diabetic is admitted with a blood sugar of 415 mg/dL. His wife states, 'He always follows his diabetic diet religiously and administers his insulin using a sliding scale twice a day.' Upon reviewing his chart, the nurse notes that the client has been hospitalized four times during the past three months for a medical diagnosis of hyperglycemia secondary to noncompliance with medical regimen. When questioned, he says, 'It's a little too complicated to keep track of when I need to eat and when I need to check my blood and take my medicine.' Which nursing diagnosis is most appropriate?
Correct Answer: D
Rationale: Repeated hospitalizations for hyperglycemia due to difficulty managing the regimen indicate noncompliance, the most appropriate diagnosis.
Question 4 of 5
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.
Question 5 of 5
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.